Why Your Operation May Not Work And Why You Should Consider Physical Therapy First
A recent article in the Sydney Morning Herald called, Confessions of a Sydney Surgeon: Why your operation may not work, a surgeon described procedures that he used to perform, that he now knows were unnecessary. In that article he says,
“In my career, I have done surgery for ‘ununited’ fractures that have already healed, removed implants that were not causing a problem, fused sore backs and ‘scoped’ sore knees. I have even re-operated on people with ineffective procedures after the first ineffective procedure was, well, ineffective.”
This is shocking on it’s face, but I think his point is that many of the procedures that he had performed have proven to be ineffective when compared to other more conservative options. And he is not alone, many of these surgical procedures are very common in the US. In the article he points out some common orthopedic procedures that he believes are questionable.
“Spinal fusion: Effective for some conditions but often done for degenerative conditions in older patients where the evidence is not that clear, the cost is high and the harms are real. Failure of spine surgery is so common that it has been given its own name: Failed Back Surgery Syndrome.”
“Spinal cord stimulators: Devices implanted in the spine to relieve chronic pain. Given the high cost it is reasonable to demand a placebo-controlled trial of their effectiveness but so far none have been done.”
“Epidural steroid injections: The “go-to” procedure when patients complain of back or leg pain. Studies show no better relief than those given a placebo saline injection.”
Spine fusion for management of low back is not clearly better than conservative management. What conservative management is it most often compared to? Physical therapy! PT can be a good option to reduce pain, improve motion and strength, and avoid the risks of a potentially unnecessary and expensive surgical procedure. This is also true for spinal cord stimulators, current studies show a very modest effect, and 1/3 of patients had some adverse effect from the device (http://www.sciencedirect.com/science/article/pii/S0304395903004986). And injections for low back pain have “insufficent evidence to support” recommending injections for use in people with pain that has been going on for more than a few weeks (http://journals.lww.com/spinejournal/Abstract/2009/01010/Injection_Therapy_for_Subacute_and_Chronic_Low.10.aspx).
“Stem cell injections: Commonly done for knee osteoarthritis and very expensive; the only blinded randomised trial from Australia showed while many patients felt better, they were just as likely to feel better with a placebo injection.”
“Knee arthroscopy: In Australia most knee arthroscopies are performed in patients aged 50 or older, largely for degenerative conditions, and there is a seven-fold variation in the rate of surgery between regions across the country. Studies show surgery is no more effective than placebo or non-operative treatment. Rates of knee arthroscopy in NSW have fallen in recent years.”
Stem cell injections are sometimes presented as an alternative to knee scopes, or a standalone treatment. For knee arthritis, neither stem cell injections nor surgery has been shown to be any better than a sham, or placebo injection or surgery. In fact for both knee arthritis, and meniscal tears, having your knee scoped has not been shown to be any better than physical therapy (http://jbjs.org/content/95/22/2058.short). So “cut” (see what I did there?) to the chase and get PT first.
Tennis elbow surgery: Another procedure that is in decline. The condition largely gets better over time and surgery doesn’t add anything to that process.
Tennis elbow surgery is become less common, but still occasionally performed. You could also include cortisone injections for tennis elbow in this group. When compared to a placebo injection, patients that had a cortisone injection did WORSE and had MORE chance of recurrence at 6 months and 1 year. If you are looking for short term pain management, physical therapy can provide similar pain relief without risking having more pain and less function at 6 months and 12 months (http://jama.jamanetwork.com/article.aspx?articleid=1568252)
So before you head off for more invasive procedures like injections or surgery, make sure you ask a lot of questions, do a little research, and consult a PT. There’s a good chance that getting PT first could prevent an unnecessary surgery and save you time and money.